Does not apply to BlueCare
Trigger point injection therapy is used for the treatment of myofascial pain syndrome (MPS). Myofascial pain is a common, non-articular musculoskeletal disorder characterized by symptomatic myofascial trigger points - hard, palpable, localized nodules within taut bands of skeletal muscle that are painful upon compression. MPS is a chronic condition affecting the connective tissue (i.e., fascia) surrounding the muscles; sensitive points in your muscles (trigger points) cause referred pain in seemingly unrelated parts of the body. MPS typically occurs after a muscle has been contracted repetitively. The large upper back muscles are prone to developing myofascial pain, as well as the neck, shoulders, heel and temporomandibular joint.
Treatment options for myofascial pain syndrome include medications, physical therapy and trigger point injections.
Pain that persists for extended periods of time (generally greater than 3 months) and fails to be alleviated with conservative approaches may be treated with injections of local anesthetics, anti-inflammatory drugs, and/or corticosteroid in an attempt to deactivate the trigger point.
Dry needling is a variant of trigger point injection and refers to a procedure in which a fine needle is inserted into the skin and muscle at the site of myofascial pain. The needle may be moved in an up-and-down motion, rotated, and/or left in place for as long as 30 minutes; no medications are given through the needle. Dry needling is not the same as acupuncture.
Trigger point injections with local anesthetics, with or without steroids, are considered medically necessary. (Note: No more than four (4) trigger point injection sessions are considered appropriate in a one year period.)
Ultrasound guidance of trigger point injections is considered not medically necessary.
Dry needling for the treatment of trigger points is considered investigational.
Any device or agent utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
Does not apply to BlueCare
There are limited comparative studies available in peer-reviewed journals to determine efficacy or utility of dry needling in the treatment of trigger points. Palpation remains the standard of care for the diagnosis of trigger points and the technique utilized in the guidance of the injections.
BlueCross BlueShield Association. Evidence Positioning System. (4:2018) Dry needling of myofascial trigger points (2.01.100) Retrieved November 16, 2018 from http://www.evidencepositioningsystem.com. (15 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (4:2017). Trigger point and tender point injections (2.01.103). Retrieved November 16, 2018 from http://www.evidencepositioningsystem.com. (18 articles and/or guidelines reviewed)
Boyles, R., Fowler, R., Ramsey, D., & Burrows, E. (2015). Effectiveness of trigger point dry needling for multiple body regions: a systematic review. Journal of Manual and Manipulative Therapy, 23 (5), 276-293. (Level 2 evidence)
CMS.gov: Centers for Medicare & Medicaid Services. Palmetto GBA. (2018, September) LCD for Trigger point injections (LCD ID: L37635). Retrieved November 16, 2018 from https://www.cms.gov.
Liu, L., Huang, Q.M., Lie, Q.G., Ye, G., Bo, C.Z., Chen, M.J., et al. (2015). Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systemic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 96 (5), 944-955. Abstract retrieved July 2, 2015 from PubMed database.
Saeidian, S., Pipelzadeh, M., Rasras, S., & Zeinali, M. (2014). Effect of trigger point injection on lumbosacral radiculopathy source. Anesthesia and Pain Medicine, 4 (4), e15500. (Level 4 evidence)
Stratton, P., Khachikyan, I., Sinaii, N., Ortiz, R., and Shah, J. (2015, March) Association of Chronic Pelvic Pain and Endometriosis With Signs of Sensitization and Myofascial Pain. Obstetrical Gynecology; 125(3): 719-728. (Level 3 evidence)
Sucuoglu, H., Ozbayrak, S., Uludag, M., and Tuzun, S. (2016, April). Short-term efficacy of joint and soft tissue injections for musculoskeletal pain: An interventional cohort study. AGRI Pain, 28 (2), 79-88. (Level 4 evidence)
Winifred S. Hayes, Inc. Medical Technology Directory. (2013, December; last update search December 2017). Trigger point injections for myofascial pain. Retrieved January 3, 2018 from www.Hayesinc.com/subscribers. (68 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2017, April).Comparative effectiveness review of dry needling for mechanical neck and/or trapezius muscle pain in adults. Retrieved January 3, 2018 from www.Hayesinc.com/subscribers. (53 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2017, June: last update search June 2018). Comparative effectiveness review of dry needling for indications other than neck or trapezius muscle pain in adults. Retrieved November 16, 2018 from www.Hayesinc.com/subscribers. (67 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 7/14/2012
MOST RECENT REVIEW DATE: 2/14/2019
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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